Exam (elaborations) NR 511 DISCUSSION PART 1 WEEK 3 (PERTINENT INFORMATION)

Exam (elaborations) NR 511 DISCUSSION PART 1 WEEK 3 (PERTINENT INFORMATION) A 19-year-old male freshman college student presents to the student health center today with complaints of bilateral eye discomfort. Upon further questioning you discover the following subjective information regarding the chief complaint. History of Present Illness Onset 2-3 days ago Location Both eyes Duration Constant Characteristics Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes the gritty sensation "like sand caught in your eye" Aggravating factors None identified Relieving factors None identified Treatments Tried OTC visine drops once yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained. Severity Level of discomfort is 2/10 on pain scale Review of Systems (ROS) Constitutional Denies fever, chills, or recent illnesses Eyes Denies contact lenses or glasses, has never experienced these symptoms previously. Last eye exam was "a few years ago". Denies eye injury, trauma, visual changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation. Ears -otalgia, -otorrhea Nose +occasional runny nose with intermittent nasal congestion, denies sneezing. History of seasonal nasal This study source was downloaded by from CourseH on 08-31-2021 14:01:38 GMT -05:00 This study resource was shared via CourseH allergies which is aggravated in the spring but is well controlled on loratadine and fluticasone nasal spray taken during peak season (he is not taking either right now). Throat Denies ST and redness Neck Denies lymph node tenderness or swelling Chest Denies cough, SOB and wheezing Heart Denies chest pain History Medication s Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare) PMH Seasonal allergic rhinitis with springtime triggers PSH None Allergies None Social Freshman student at the University of Awesome located in central Illinois. Home is in Phoenix. Habits Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend FH Adopted, does not know biological parents history Physical exam reveals the following. Physical Exam Constitutional Young adult male in NAD, alert and oriented, cooperative VS Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds Head Normocephalic Eyes Visual Acuity 20/20 (uncorrected) OU. PERRL with white sclera bilaterally. Slight light sensitivity noted bilaterally. No crusting, lesions or masses on lids noted. Bilateral conjunctiva with diffuse This study source was downloaded by from CourseH on 08-31-2021 14:01:38 GMT -05:00 This study resource was shared via CourseH redness and tearing but no mucoid or purulent drainage noted.e No visible FBs under lids or on cornea to gross examination. Fundiscopic examination: Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color. Ears Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nose Nares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear. Throat Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonar Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. 1. Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information. M.J is a 19 yo male with a CC of both eye discomfort x 2 to 3 days. He describes his discomfort as foreign body sensation in his eyes. He c/o grittiness, epiphora (tearing), redness, and ocular pruritis on both eyes which did not resolve from one-time usage of OTC visine. He is also positive for occasional rhinorrhea (runny nose) with intermittent nasal congestion which are subsided with loratadine and fluticasone nasal spray during spring season. Physical exam confirms that the patient is positive for bilateral OU photophobia (light sensitivity), conjunctival hyperemia and epiphora. He is also positive for nasal turbinate hypertrophy and rhinorrhea which is clear. 2. Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each. 1) Allergic conjunctivitis (AC) Allergic conjunctivitis (AS) is mainly due to IgE-mediated hypersensitivity reaction. (La Rosa et al., 2013). Akil, Celik, Ulas, & Kara (2015) also mentioned from their citation that AC is caused by activation of Tcells as well as increased inflammatory cytokines which are epidermal growth factor, interleukin-1 (IL-1), and IL-8, affect goblet cells and conjunctival epithelial. Berger, Granet, & Kabat (2017) cited that allergic conjunctivitis occurs when conjunctival tissue responses to allergens such as animal dander, pollen, and other environmental allergens. They also cited that antigen exposure initiates mast cell degranulation and histamine release which triggers whole body inflammatory response (Berger et al., 2017). Furthermore, Akil et al., (2015) cited that these mechanism results in decreased mucin which causes decreased tear formation. 2) Allergic rhinitis (AR) This study source was downloaded by from CourseH on 08-31-2021 14:01:38 GMT -05:00 This study resource was shared via CourseH AR is the most common form of noninfectious rhinitis which is associated with an IgE-mediated immune response against allergens, such as dust mites, grass pollen tree pollen, weed pollens, cat, dog, and molds (Gentile, Bartholow, Valovirta, Scadding, & Skoner, 2013). Gentile et al. (2013) cited that IgE antibodies are created from previous exposure to allergen and stays on the surface of mast cells which triggers mast cell degranulation with re-exposure to allergen. They also cited that this mechanism results in release of histamine which a